A nurse is assessing a patient with a hemoglobin level of 7 g/dL.
What is the appropriate indication for blood transfusion based on this hemoglobin level?
"I'm feeling weak and dizzy.”
"My hemoglobin is 7 g/dL, so I need a transfusion.”
"I had orthopedic surgery yesterday.”
"I have a stable cardiovascular disease.”
The Correct Answer is B
Choice A rationale:
"I'm feeling weak and dizzy." Rationale: Weakness and dizziness can be symptoms of anemia, which is often associated with low hemoglobin levels.
However, these symptoms alone are not a definitive indication for blood transfusion.
Other factors, such as the patient's overall clinical condition and the cause of the low hemoglobin, need to be considered.
Choice B rationale:
"My hemoglobin is 7 g/dL, so I need a transfusion." Rationale: This statement indicates that the patient is aware of their low hemoglobin level and believes they need a transfusion.
The hemoglobin level of 7 g/dL is a common threshold used as an indication for blood transfusion, especially in symptomatic patients.
This choice is correct because it aligns with the appropriate clinical indication for a transfusion based on the hemoglobin level.
Choice C rationale:
"I had orthopedic surgery yesterday." Rationale: While surgery can lead to blood loss, the statement alone does not provide sufficient information to determine if a transfusion is necessary.
The decision to transfuse blood should be based on the patient's hemoglobin level, overall clinical condition, and the extent of blood loss during surgery.
Choice D rationale:
"I have a stable cardiovascular disease." Rationale: The presence of stable cardiovascular disease is not directly related to the need for a blood transfusion based on a hemoglobin level of 7 g/dL.
The decision to transfuse should primarily be based on the patient's hemoglobin level and symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) typically presents with symptoms of fever, rash, diarrhea, and pancytopenia 1 to 6 weeks after transfusion.
It is a delayed reaction, but it does not cause epistaxis, hematuria, and menorrhagia, which are bleeding symptoms.
Therefore, it is an unlikely choice for this scenario.
Choice B rationale:
Transfusion-related immunomodulation (TRIM) is a theory that blood transfusions may affect the immune system, but it does not typically present with the specific bleeding symptoms described in the scenario.
TRIM is more concerned with the immunosuppressive effects of transfusions.
Choice C rationale:
Post-transfusion purpura is a rare condition that occurs 5 to 12 days after a transfusion.
It is characterized by sudden severe thrombocytopenia (low platelet count) and bleeding symptoms, which can include epistaxis (nosebleeds), hematuria (blood in the urine), and menorrhagia (excessive menstrual bleeding)
This aligns with the symptoms described in the scenario, making it the most likely cause.
Choice D rationale:
Viral infections can be a complication of blood transfusions, but they do not typically present with these specific bleeding symptoms within 7 days after the transfusion.
Viral infections may cause a broader range of symptoms and have a longer incubation period.
Correct Answer is B
Explanation
Choice A rationale:
Verifying the patient's identification is an essential step in patient safety, but it alone does not ensure transfusion safety.
Transfusion safety involves multiple steps beyond identification.
Choice B rationale:
Maintaining aseptic technique and infection control practices is crucial during a blood transfusion.
This includes using sterile equipment, wearing gloves, and following proper hand hygiene.
Infection can be a severe complication of transfusion if proper precautions are not taken.
Choice C rationale:
Administering blood products using old and sterile equipment is not a safe practice.
Blood transfusions require the use of fresh, sterile equipment to prevent contamination and ensure patient safety.
Choice D rationale:
Monitoring the patient's condition only after the transfusion is not sufficient to ensure safety.
Continuous monitoring during the transfusion is necessary to detect and respond to any adverse reactions promptly.
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